Current through November 28, 2024
(a) A fee or other
charge for medical treatment or service may not exceed the maximums in
AS
23.30.097. The fee or other charge for
medical treatment or service
(1) provided on
or after December 1, 2015, but before April, 2017, may not exceed the fee
schedules set out in (b) - (l) of this section;
(2) provided on or after April 1, 2017, but
before January 1, 2018, may not exceed the maximum allowable reimbursement
established in the
Official Alaska Workers' Compensation Medical Fee
Schedule, effective April 1, 2017, and adopted by reference;
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(3) provided on or after January 1, 2018, but
before January 1, 2019, may not exceed the maximum allowable reimbursement
established in the
Official Alaska Workers' Compensation Medical Fee
Schedule, effective January 1, 2018, and adopted by
reference.
(4) provided on or after
January 1, 2019, but before January 1, 2020, may not exceed the maximum
allowable reimbursement established in the
Official Alaska Workers'
Compensation Medical Fee Schedule, effective January 1, 2019, and
adopted by reference.
(5) provided
on or after January 1, 2020, but before January 1, 2021, may not exceed the
maximum allowable reimbursement established in the
Official Alaska
Workers' Compensation Medical Fee Schedule, effective January 1, 2020,
and adopted by reference;
(6)
provided on or after January 1, 2021, but before February 24, 2022, may not
exceed the maximum allowable reimbursement established in the
Official
Alaska Workers' Compensation Medical Fee Schedule, effective January
1, 2021, and adopted by reference;
(7) provided on or after February 24, 2022,
but before January 1, 2022, may not exceed the maximum allowable reimbursement
established in the
Official Alaska Workers' Compensation Medical Fee
Schedule, January 1, 2022 edition, adopted by reference.
(8) provided on or after January 29, 2023,
but before January 1, 2024, may not exceed the maximum allowable reimbursement
established in the
Official Alaska Workers' Compensation Medical Fee
Schedule, January 1, 2023 edition, and adopted by reference;
(9) provided on or after January 1, 2024, but
before January 1, 2025, may not exceed the maximum allowable reimbursement
established in the
Official Alaska Workers' Compensation Medical Fee
Schedule, January 1, 2024 edition, and adopted by reference;
(10) provided on or after January 1, 2025,
may not exceed the maximum allowable reimbursement established in the
Official Alaska Workers' Compensation Medical Fee Schedule,
January 1, 2025 edition, and adopted by reference.
(b) For medical services provided by
physicians under AS 23.30 (Alaska Workers' Compensation Act) the following
conversion factors shall be applied to the total facility or non-facility
relative value unit in the Resource-Based Relative Value
Scale, adopted by reference in (m) of this section. Medical service or
treatment shall be identified by a code assigned to that treatment or service
in the Current Procedural Terminology, adopted by reference in
(m) of this section:
(1) the conversion
factor for evaluation and management is $80;
(2) the conversion factor for medicine,
excluding anesthesiology, is $80;
(3) the conversion factor for surgery is
$205;
(4) the conversion factor for
radiology is $257;
(5) the
conversion factor for pathology and laboratory is $142;
(6) the relative value for
Current
Procedural Terminology code 97545 is 3.41, and the relative value for
Current Procedural Terminology code 97546 is
1.36.
(c) The conversion
factor for anesthesiology is $121.82, which is to be multiplied by the base and
time units for each Current Procedural Terminology code
established in the Relative Value Guide, adopted by reference in (m) of this
section.
(d) For supplies,
materials, injections, and other services and procedures coded under the
Healthcare Common Procedure Coding System, adopted by
reference in (m) of this section, the following multipliers shall be applied to
the following fee schedules established by the Centers for Medicare and
Medicaid Service and in effect at the time of treatment or service;
(1) Clinical Diagnostic Laboratory services,
multiplied by 6.33;
(2) Durable
Medical Equipment, Prosthetics, Orthotics, and supplies (DMEPOS), multiplied by
1.84;
(3) Average Sale Price,
Payment Allowance Limits for Medicare Part B Drugs, multiplied by
3.375;
(e) For medical
services provided by inpatient hospitals under AS 23.30 (Alaska Workers'
Compensation Act) the conversion factor of 328.2 percent of the hospital
specific total base rate shall be applied to the Medicare Severity
Diagnosis Related Groups weight adopted by reference in (m) of this
section, except that
(1) the maximum
allowable reimbursement for medical services provided by a critical access
hospital, rehabilitation hospital, or long term acute care hospital is the
lowest of 100 percent of billed charges, the charge for the treatment or
service when provided to the general public, or the charge for the treatment or
service negotiated by the provider and the employer;
(2) the base rate for Providence Alaska
Medical Center is $23,383.10;
(3)
the base rate for Mat-Su Regional Medical Center is $20,976.66;
(4) the base rate for Bartlett Regional
Hospital is $20,002.93;
(5) the
base rate for Fairbanks Memorial Hospital is $21,860.73;
(6) the base rate for Alaska Regional
Hospital is $21,095.72;
(7) the
base rate for Yukon Kuskokwim Delta Regional Hospital is $38,753.21;
(8) the base rate for Central Peninsula
General Hospital is $19,688.56;
(9)
the base rate for Alaska Native MedicaI Center is $31,042.20;
(10) the base rate for Mt. Edgecumbe Hospital
is $26,854.53;
(11) on outlier
cases, implants shall be paid at invoice plus 10 percent.
(f) For medical services provided by hospital
outpatient clinics or ambulatory surgical centers under AS 23.30 (Alaska
Workers' Compensation Act), an outpatient conversion factor of $221.79 shall be
applied to the relative weights established for each Current Procedural
Terminology or Ambulatory Payment Classification code adopted by
reference in (m) of this section. For procedures performed in an outpatient
setting, implants shall be paid at invoice plus 10 percent.
(g) The maximum allowable reimbursement for
medical services that do not have current Centers for Medicare and Medicaid
Services, Current Procedural Terminology, or Healthcare Common
Procedure Coding System codes, a currently assigned Centers for
Medicare and Medicaid Services relative value, or an established conversion
factor is the lowest of 85 percent of billed charges, the charge for the
treatment or service when provided to the general public, or the charge for the
treatment or service negotiated by the provider and the employer.
(h) The maximum allowable reimbursement for
prescription drugs is as follows:
(1) brand
name drugs shall be reimbursed at the manufacturer's average wholesale price
plus a $5 dispensing fee;
(2)
generic drugs shall be reimbursed at manufacturer's average wholesale price
plus a $10 dispensing fee;
(3)
reimbursement for compounded drugs shall be limited to medical necessity and
reimbursed at the manufacturer's average wholesale price for each drug included
in the compound, listed separately by National Drug Code, plus a $10
compounding fee.
(i) The
maximum allowable reimbursement for lift off fees and air mile rates for air
ambulance services rendered under AS 23.30 (Alaska Workers' Compensation Act)
is as follows:
(1) for air ambulance services
provided entirely in this state that are not provided under a certificate
issued under 49 U.S.C.
41102 or that are provided under a
certificate issued under 49
U.S.C. 41102 for charter air transportation
by a charter air carrier, the maximum allowable reimbursements are as follows:
(A) a fixed wing lift off fee may not exceed
$11, 500;
(B) a fixed wing air mile
rate may not exceed 400 percent of the Centers for Medicare and Medicaid
Services ambulance fee schedule rate in effect at the time of
service;
(C) a rotary wing lift off
fee may not exceed $13, 500;
(D) a
rotary wing air mile rate may not exceed 400 percent of the Centers for
Medicare and Medicaid Services ambulance fee schedule rate in effect at the
time of service;
(2) for
air ambulance services in circumstances not covered under (1) of this
subsection, the maximum allowable reimbursement is 100 percent of the billed
charges.
(j) The
following billing and payment rule apply for medical treatment or services
provided by Physicians. Providers and payers shall follow the billing and
coding rules adopted by reference in (m) of this section as established by the
Centers for Medicare and Medicaid Services and the American Medical
Association, including the use of modifiers. The procedure with the largest
relative value unit is the primary procedure and shall be listed first on the
claim form. Specific modifiers shall be reimbursed as follows:
(1) Modifier 50: reimbursement is the lowest
of 100 percent of the fee schedule amount or the billed charge for the
procedure with the highest relative value unit; reimbursement is the lowest of
50 percent of the fee schedule amount or the billed charge for the procedure
for the second and all subsequent procedure;
(2) Modifier 51: reimbursement is the lowest
of 100 percent of the fee schedule amount or the billed charge for the
procedure with the highest relative value unit rendered during the same session
as the primary procedures; reimbursement is the lowest of 50 percent of the fee
schedule amount or the billed charge for the procedure for the second highest
relative value unit and all subsequent procedures during the same session as
the primary procedure;
(3) Modifier
80, 81 and 82: reimbursement is 20 percent of the surgical procedure;
(4) Modifier PE: reimbursement is 85 percent
of the value of the procedure; state specific modifier PE shall be used when
services and procedures are provided by a physician assistant or an advanced
practice registered nurse;
(5)
Modifier AS: reimbursement is 15 percent of the value of the procedure; state
specific modifier AS shall be used when a physician assistant or nurse
practitioner acts as an assistant surgeon and bills as an assistant
surgeon;
(6) Modifier QZ:
reimbursement is 85 percent of the value of the anesthesia procedure; state
specific modifier QZ shall be used when unsupervised anesthesia services are
provided by a certified registered nurse anesthetist;
(7) providers and payers shall follow
National Correct Coding Initiative edits established by the Centers for
Medicare and Medicaid Services and the American Medical Association in effect
at the time of treatment; if there is a billing rule discrepancy between
National Correct Coding Initiative edits and the American Medical Association
Current Procedural Terminology Assistant, American Medical
Association
Current Procedural Terminology Assistant guidance
governs.
(k) The
following billing and payment rules apply for medical treatment or services
provided by inpatient hospitals, hospital outpatient clinics, and ambulatory
surgical centers:
(1) medical service for
which there is no
Ambulatory Payment Classifications weight
listed are the lowest of 85 percent of billed charges, the fee or charge for
the treatment or service when provided to the general public, or the fee or
charge for the treatment or service negotiated by the provider and the
employer;
(2) status codes C, E,
and P are the lowest of 85 percent of billed charges, the fee or charge for the
treatment or service when provided to the general public, or the fee or charge
for the treatment or service negotiated by the provider and the
employer;
(3) two or more medical
procedures with a status code T on the same claim shall be reimbursed with the
highest weighted code paid at 100 percent of the
Ambulatory Payment
Classifications calculated amount and all other status code T items
paid at 50 percent;
(4) a payer
shall subtract implantable hardware from a hospital outpatient clinic's or
ambulatory surgical center's billed charges and pay separately at manufacturer
or supplier invoice cost plus 10 percent;
(5) if total costs for a hospital inpatient
Medicare Severity Diagnosis Related Groups coded service
exceeds the Centers for Medicare and Medicaid Services outlier threshold
established at the time of service plus the
Medicare Severity Diagnosis
Related Groups payment, then the total payment for that service shall
be calculated using the Centers for Medicare and Medicaid Services Inpatient PC
Pricer tool as follows:
(A) implantable
charges, if applicable, are subtracted from the total amount charged;
(B) the charged amount from (A) of this
paragraph is entered into the most recent version of the Centers for Medicare
and Medicaid Services PC Pricer tool at the time of treatment;
(C) the Medicare price returned by the
Centers for Medicare and Medicaid Services PC Pricer tool is multiplied by 2.5,
or 250 percent of the Medicare price;
(D) the allowable implant reimbursement, if
applicable, is the invoice cost of the implant plus 10 percent, or 110 percent
of invoice cost;
(E) the amounts
calculated in (C) and (D) of this paragraph are added together to determine the
final reimbursement.
(l) For medical treatment or services
provided by other providers, the maximum allowable reimbursement for medical
services provided b providers other than physicians, hospitals, outpatient
clinics, or ambulatory surgical centers is the lowest of 85 percent of billed
charges, the fee or charge for the treatment or service when provided to the
general public, or the fee or charge for the treatment or service negotiated by
the provider and the employer.
(m)
The following material is adopted by reference:
(1)
Current Procedural Terminology
Codes, 2015 edition, produced by the American Medical Association, as
may be amended;
(2)
Healthcare Common Procedure Coding System, 2015 edition,
produced by the American Medical Association, as may be amended;
(3)
International Classification of
Diseases, 10th Revision, Clinical Modification, developed by the
National Center for Health Statistics, as may be amended;
(4)
Relative Value Guide,
2015 edition, produced by the American Society of Anesthesiologists, as may be
amended;
(5)
Diagnostic and
Statistical Manual of Mental Disorders, 5th edition, produced by the
American Psychiatric Association, as may be amended;
(6)
Current Dental
Terminology, 2015 edition, published by the American Dental
Association, as may be amended;
(7)
Resource-Based Relative Value Scale, effective January 1, 2015
produced by the federal Centers for Medicare and Medicaid Services, as may be
amended;
(8)
Ambulatory
Payment Classifications, effective January 1, 2015 produced by the
federal Centers for Medicare and Medicaid Services, as may be
amended;
(9)
Medicare
Severity Diagnosis Related Groups, effective January 1, 2015 produced
by the federal Centers for Medicare and Medicaid Services, as may be
amended;
(10)
Hospital
Outpatient Prospective Payment System, produced by the federal Centers
for Medicare and Medicaid Services;
(11)
Clinical Diagnostic Laboratory
Services, produced by the federal Centers for Medicare and Medicaid
Services, as may be amended;
(12)
Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies, produced by the federal Centers for Medicare and Medicaid
Services, as may be amended;
(13)
Payment Allowance Limits for Medicare Part B Drugs, Average Sale
Price, produced by the federal Centers of Medicare and Medicaid
Services, as may be amended;
(14)
Ambulance Fee Schedule, produced by the federal Centers for
Medicare and Medicaid Services, as may be amended.
(n) In this section, "maximum allowable
reimbursement" means the charge for medical treatment or services calculated in
accordance with the fee schedule.
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The Hospital Outpatient Prospective Payment System is
available on the Centers for Medicare and Medicaid Services website at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.
On January 4, 2024, as required by
AS
23.30.098 and
AS
44.62.245, the department gave notice that
the following amended versions of material, previously adopted by reference in
8 AAC 45.083(m), would be in effect on January 1, 2024: the Current Procedural
Terminology Codes, 2024 edition, produced by the American Medical Association;
the Healthcare Common Procedure Coding System (HCPCS), 2024 edition, produced
by the American Medical Association; the Relative Value Guide, 2024 edition,
produced by the American Society of Anesthesiologists; the Current Dental
Terminology, 2024 edition, published by the American Dental Association; the
Resource-Based Relative Value Scale, effective January 1, 2024, produced by the
federal Centers for Medicare and Medicaid Services; the Ambulatory Payment
Classifications, effective January 1, 2024, produced by the federal Centers for
Medicare and Medicaid Services; and the Medicare Severity Diagnosis Related
Groups, effective January 1, 2024, produced by the federal Centers for Medicare
and Medicaid Services. The amended versions may be reviewed at the Department
of Labor and Workforce Development, Division of Workers' Compensation, 1111 W
8th Street, Suite 305, Juneau, Alaska 99811; telephone (907)
465-2790.
Authority:
AS 23.30.005
AS 23.30.097
AS 23.30.098
